The First Winner in the Investigator Award;
The 10th International Meeting on Respiratory Care Indonesia (RESPINA) 2008
FULL PAPER
THE EFFECT OF WALK EXERCISE ON LAP AND
ST. GEORGE QUESTIONNAIRE IN PATIENTS WITH MODERATE CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Sari Dewi Saraswati; Nury Nusdwinuringtyas; Tri Damiati Panji; Hadyana Sukandar
INTRODUCTION : Chronic obstructive pulmonary disease (COPD) is incurable disease and in most patients it is progressive.(1) In COPD patients, a condition of progressive disability and handicap are characterized with the decrease of exercise capacity.
One of rehabilitation programme for COPD is reconditioning exercise, which aims to enhance the physical capacity and the ability of daily living activities. The types of exercise include cardiopulmonary endurance.(2) The exercise is usually related to the exercise using large muscle group, that is, the muscles of lower extremities.
In resulting appropriate reconditioning to the purpose of the exercise, the walk exercise should be a specific programme due to the patients have limited lung functions.
Problem Identification: Could the program of walk exercise in patients with moderate COPD increase the lap and reduce SGRQ score?
Study Objective: To assess the effect of walk exercise on the change of lap and SGRQ score in patients with moderate COPD.
In exercise of endurance, programme was made measurable and directed, as well as monitored in order to obtain the expected results. In this programming of endurance exercise, four aspects should be noticed, i.e., intensity, duration, frequency, and type of exercise.
The effect of Exercise on COPD: In COPD, there is an abnormality in mechanism of respiratory system, that is, the ability to increase ventilation in agreement to the demand of oxygen supply for exercise due to breathless as the main complaint. Beside the presence of limited respiratory capacity, the peripheral muscular disfunction and muscular fatigue also limit the exercise capacity leading to reduced exercise tolerance. In the fact, the training programme applied to the patients is able to increase exercise tolerance.
The important principles should be applied the progamme: (3,21)
1. The specification of the training. Endurance exercise increases the number of capillary blood vessels.
2. Frequency, intensity, duration, and length of training. Threshold training effect is achieved at several 20‑ to 30-minute exercises in a week leading to increased endurance. The effect of 8-week training is able to show the increased cardiopulmonary endurance.(13,14,15,16)
3. Detraining effect. When the training is withdrawn, the results of training achievement will fade away. This indicates the importance of continuous exercise.(24)
It assumed that the more efficient peripheral oxygen utility resulted from the muscle agility and endurance will give an increase in cardiovascular and respiratory functions; resulting an increased cardiopulmonary endurance of patients with COPD. Besides, improved respitory muscle endurance, heightened motivation, reduced sensitivity against shortness of breath, and improved exercise capacity.(20)
Walk exercise for COPD patients:
Intensity: In training programme according to the American College of Sport Medicine, the training intensity for walk endurance is adjusted to each individual capacity. Walk exercise can be carried out by measuring intensity using Borg’s subjective work scale.(25,31) It refers to the subjective scale at which the magnitude of body capability to exert exercise work at a given time (Borg 1998). The values of work score have a range from 1 to 12 Borg scale (14,15,25,31) denoting a work exerted.
Exercise duration : Exercise was performed within 10 minutes per session and 3-5 minute resting period was applied every 2-3 exercise sessions.(3) Exercise conducted with 30-minute duration for 5 sessions can enhance adaptation to training tolerance. (1)
The optimal frequency of exercise is 3 to 4 times per week. This is certainly individual.(1,21) The average exercise period is 6-8 week.
6-Minute Walk Test (6-MWT): 6-MWT is a measuring instrument by walking reciprocally along a 30-m lap without cheer within 6 minutes. The outcome of this test is lap time. Lap distance is estimated from body weight and height adjusted to gender. Walk test is easily carried out, well tolerated by patients with COPD, and its safety and reliability have been assessed.
SGRQ is a specific questionnaire for assessing the quality of life of patients with chronic airway disease; it has been developed by PW Jones et al.(30) The questionnaire consists of 76 items which are divided into three components: the symptoms of the disease, activity, and implication.
Research Design
Experimental study with complete randomized design was conducted on pre- and post-treatment repetitive observation. This study was divided into two groups, a walk exercise group and control group.
Settings: Medical Rehabilitation, dr. Hasan Sadikin Hospital, Bandung. It was conducted from December 2006 to March 2007.
Reachable Population: Patients with moderate Chronic Obstructive Pulmonary Disease admitted to Sub-Department of Pulmonology, Department of Internal Medicine, dr. Hasan Sadikin Hospital, Bandung.
Inclusion Criteria:
1. The out-patient had been diagnosed moderate COPD at Clinic of Pulmonology, Department of Internal Medicine, dr. Hasan Sadikin Hospital, without acute exacerbation.
2. Male or female of 55-75 years old.
3. Walk able without support device.
4. Cooperative and agreed to participate in the study and ready to conduct walk exercise; all were stated in informed consent.
5. Had no regular sport activity.
Exclusion criteria:
1. Suffering neuromusculoskeletal disorder, particularly in lower extremity.
2. The patient refused to participate in the study.
Drop-out criteria:
When the patient did not perform exercise 4 times consecutively, he or she is considered to be drop-out.
Variables
a. Independent variables: Walk exercise
b. Dependent variables : SGRQ score and Lap
Research Management
1. All subjects who met the inclusion criteria were examined after diagnosis moderate COPD at Clinic of Pulmonology, Department of Internal Medicine, dr. Hasan Sadikin Hospital, Bandung
2. Every subject who met the inclusion criteria received:
a. Anamnesis
b. Physical Examination
c. Signing the informed consent to participate in the reseach
d. 6-MWT (the procedure enclosed in Appendix)
e. Filling-out the SGRQ questionnaire form
3. Subjects were divided into two groups, a training group and a control group.
4. All subject got education on:
a. The purpose and objectives of walk test and how to do it clearly untill they can do it well.
b. How to use Borg scale during exercise.
5. The training programme for group was held at the Hospital under supervision of the researcher. That for control group was not under supervision.
6. The implementation of the procedure was:
a. The general condition of the subjects examined at sitting position was: blood pressure, pulse, and respiratory rate within one minute.
b. Borg scale was used to measure : work, breathless, and muscular fatigue.
c. The subjects were instructed to do stretching exercise.
d. Subjects were asked to do walk with intensity at Borg scale 12 (work more than mild). Stopwatch started.
e. After the first 10-minute walk, the subjects were asked to take 3-minute by sitting.
f. Then, the subjects were asked to restart walk with the similar intensity for the second 10-minutes.
g. Next, they were asked to stop walk and do second 3-minute rest by sitting.
h. In the same way, subsequently, the subjects were asked to restart walk with the similar intensity for the third 10-minutes.
i. Next, they should stop walking.
j. They did stretching exercise.
k. They finished their exercise.
Finally, they were examined at sitting position for their blood pressure, pulse, and respiratory rate within one minute, and Borg scale.
Drop-out from exercise when appear :
· left chest pain (angina-like symptom).
· Fatigue or “heavy”sensation in chest.
· Sign of reduced blood perfusion, such as dark-sight, parlour, nausea.
7. At the end of 4th and 8th weeks, the subjects in each group got 6-MWT; and at the end of the study, SGRQ assessment was conducted.
8. The results of 6-MWT laps and SGRQ scores at the end of study were compared to those of the beginning of the training.
Data Analysis
The method of data analysis used in this study for the enhancement of laps, pre-treatment and post-treatment SGRQ was paired t-test or Wilcoxon ZW-test (Wilcoxon test) and t-test for unpaired or Mann-Whitney test if the distribution is not normal. The significance was determined at p level<0.05.>
All data were processed using SPSS program for Windows version 13.0.
STUDY RESULTS
The percentage of different lap distance 6-MWT I and III in training group increased by 30,8%, whereas in control group reduced by 12,6% significantly (p<>
The subject characteristics: Subject ages ranged 55 to 70 years in training group with the mean age was 66.8 years (SD=4.4); while in control group the mean age was 63.2 years (SD=7.3). it implies statistically non-significant. Calculated BMI indicated the mean BMI of the training group was 22.5 (SD=4.0) and in control group it was 22.0 (SD=2.7), implying nonsignificant. Mean FEV1 percentage in training group was 71.5 (SD=7.9) and in control group was 73.3 (SD=2.6), implying nonsignificance.
The different percentage of laps at 6-MWT I and III in training group increased by 30.8%, whereas in control group reduced by 12.6% very significantly (p<0.05).>
Figure 1. Chart of The Change in Distance on 6 Minute Walking Exercise (6-MWT) I (Week 0), II ( Week 4th), dan III ( Week 8th).
The total score of SGRQ percentage in training group reduced by 17.9%, while in control group it increased by 10.1%.
Figure 2. Chart of Change in Total Score SGRQ I dan II.
The overall SGRQ of symptoms, activity and implication, only implication in training group revealed significant score.
Figure 3. Chart of Score Change in Impact Component SGRQ I dan II.
DISCUSSION
The mean lap distances at 6-MWT I, II and III in training group were 276.9 m (SD=72.2), 329.6 m (SD=54.1), and 352.2 m (SD 58.8), respectively. The significantly increased lap distance indicated the presence of implication of training against functional capacity of 6-minute walk since the fourth week.
The difference of mean lap distance at 6-MWT II and III increased nonsignificantly because the greatest effect of training occurred at the first four weeks in untrained subjects; while in the following four weeks, the increase occurred but nonsignificatly.
In obtaining the more sigificant lap distance, it is enabled by increasing of intensity or duration.
Total SGRQ score values of training group indicated very significantly reduction; whereas those of control group indicated nonsignificant reduction with p>0.05.
Among SGRQ components of symptoms, activity, and implication in training group, the only significantly reduced score was the implication as shown at Table 5.9. Thus, the effect of training only implicated on social and psycological aspects.
Training implication did not reduce the breathless symptom in both groups.
Factor of respiratory problems within one year, listed in part Symptoms in the questionnaire whose answers in the sum of first and final scores, did not implicate on reducing the scores.
Activity component indicated nonsignificantly reduced scores in training group. In this training group, there was a possible reduction in breathless symptoms against activity (from 50.6 [SD=20.4] to 42.9 [SD=24.6]), although nonsignificantly. Meanwhile, in the control group, there was a increase in breathless symptoms against activity (from 44.7 [SD=20.6] to 49.0 [SD=26.6]).
In training group, when the increased lap distance was associated to SGRQ components up to week-8, there was a significant increase in implication; indicating that the magnitude of differences in lap distance at 6-MWT were associated to the improvement of implication component based on SGRQ score.
The implication of walk exercise against work in Borg scale was unclear due to the different score was non significant when compared to control group.
At week-8 pre 6-MWT, there was a compromised breathless symptom in control group, however, that of each group was reduced nonsignificantly.
Fatigue of Borg scale at week-8 pre and post 6-MWT were significantly different between training group and control group. The implication of training against fatigue reduced after 8 weeks.
There was an significant association between implication component on SGRQ and lap distance I-III and II-III. It can be concluded that training effect can enhance lap distance and reduce SGRQ score of implication component. .
Conclusion
1. There was an increased lap distance at 6-MWT in patient with moderate COPD in training group compared to that of control group.
2. The greatest increment of lap distance 6-MWT was at week-4.
3. There was a reduced SGRQ score in training group of patients with moderate COPD compared to that in control group. Of the SGRQ components, implication provides significant improvement.
4. Implication component have an association with lap distance 6-MWT.
